Case study 3(a) – Inhalation of fumes on deck
Crew 1 inhaled the fumes emitted from nearby fuel tank vent head for about 30 minutes while transferring work equipment to Crew 2, who was in the cargo hold. Thereafter, Crew 1 assisted Crew 2 in CH for maintenance. While assisting Crew 2, Crew 1 informed that he was not feeling well, and he was asked to rest for the whole day. Crew 1 continued to feel unwell for the next 12 days and stayed in his cabin. Crew 1 experienced headache, stomach discomfort, body muscular ache and diarrhoea. During this time, master and chief officer communicated with the company personnel (CP) to update Crew 1’s condition. CP also consulted local doctor twice regarding Crew 1’s condition and relay the doctor’s advice to the vessel. On the morning of day 12, Crew 1 was found dead in his cabin.
Why did it happen?
Risk assessment was completed for the CH job. However, inhalation of fuel oil fumes was not identified as part of the hazards. Furthermore, Crew 1 was standing at the leeway side when transferring work equipment to Crew 2 where fuel oil fumes from the vent heads accumulated. No one consulted the fuel oil’s MSDS to acknowledge remedial action for inhalation. With reference to the autopsy report, the medicine recommended by the local doctor was suitable for Crew 1’s condition, however, it was not relayed by CP to the master.
Commentary
Although there were other probable contributing factors to this incident, the focus here is on MSDS to serve as a reminder that it is an important reference document when dealing with the related incident. For this case, it is fuel oil.
Case study (3b) – Fell on cargo hold vertical ladder landing while climbing the ladder
Crew were assigned to collect cargo, Pet Coke sample inside the cargo hold (CH). The method to collect sample in this case was to have one crew (CA) standing on deck outside CH booby hatch, and another crew (CB) climbed down the vertical ladder to collect the sample. A bucket was lowered by CA on deck to CB inside the CH. All CH hatch covers were partially opened to ventilate the CH for safe man entry. However, the moment CH hatch covers were opened, crew members immediately proceeded to collect samples.
After filling sample in CH, CA pulled up the bucket while CB climbed up the vertical ladder of CH. CA heard CB, who was still inside CH, shouted. Thereafter, CA saw CB lying face down on CH’s vertical ladder landing area. CA called for help.
Subsequently, ship crew managed to bring CB on deck. Master sought assistance from shore to convey CB to shore medical facility. Meantime, second officer administered CPR on CB while waiting for shore medical transportation. When CB was conveyed to hospital, he was pronounced dead on arrival.
Why did it happen?
Vessel was provided with a safety data sheet (SDS) on Pet Coke, which is a cargo dust. The SDS outlined comprehensive safety precaution when handling Pet Coke, including inhalation, skin and eye contact; along with exposure controls with appropriate personal protective equipment to be donned. None of the requirements in the SDS was complied with. There was no risk assessment for the task of entering CH to collect cargo sample being carried out. The vessel had personal multiple gas detection meters; crew who entered the CH did not wear them. It was noted that none of the requirements in the SDS was complied with.
Crew carried out toolbox meeting on the day of incident for connect crane grab, drop anchor and enclosed space entry. Such meeting was documented in a form. The hazard categories in the form were checked for weather, moving objects, manual handling, unfamiliar personnel, tools and other. There was a hazard category of ‘Hazardous subs’, which were not checked.
Commentary
Similar to case study 3(a) above, there were other probable contributing factors to this incident, e.g., failure in crew in complying with SMS, etc. However, the focus here is on SDS, which could not be emphasised enough of its importance even before carrying out a planned task.